癌症病患常見問題的處理

血液暨腫瘤科R5 林煥超

Multidiscipline Treatment of Cancer

• Clinical oncologist

• Surgeon

• Radiation oncologist

• Pathologist

• Radiologist

The Description of Cancer Patients

1.The pattern of presenting symptoms and signs.

2.The evidence of diagnosis.

3.The disease extent.

4.The treatment plan.

5.The effects and side effects of treatments.

6.The ongoing problems.

Pathophysiology of Cancer

• Local effects:

1. Tumor necrosis, infection, bleeding.

2. Tumor invasion of adjacent structure.

Pathophysiology of Cancer

• Remote effects:

1. Tumor production:

hormones, growth factors, cytokines,

other peptides.

2. Tumor-evoked production:

a. Immune cells: antibodies, immune complex.

b. Non-immune cells: other peptides.

如何給予化學治療藥物

DNA synthesisAntimetabolitesAntimetabolites

DNA

DNA transcription DNA duplication

Mitosis

Alkylating agentsAlkylating agents

Spindle poisonsSpindle poisons

Intercalating agentsIntercalating agentsCellular levelCellular level

Action sites of cytotoxic agents

6-MERCAPTOPURINE

6-THIOGUANINE

METHOTREXATE

5-FLUOROURACIL

HYDROXYUREA

CYTARABINE

PURINE SYNTHESISPURINE SYNTHESIS PYRIMIDINE SYNTHESISPYRIMIDINE SYNTHESIS

RIBONUCLEOTIDESRIBONUCLEOTIDES

DEOXYRIBONUCLEOTIDESDEOXYRIBONUCLEOTIDES

DNADNA

RNARNA

PROTEINSPROTEINS

MICROTUBULESMICROTUBULESENZYMESENZYMES

L-ASPARAGINASE

VINCA ALKALOIDS

TAXOIDS

ALKYLATING AGENTS

ANTIBIOTICS

ETOPOSIDE

Action sites of cytotoxic agents

化學治療可以 延長轉移患者的存活期 @ Primary chemotherapy 減輕癌症引起的不適 @ Palliative chemotherapy 增加手術或放射治療的療效 @ Neoadjuvant & adjuvant @ Concommitent radiosensitizer 改善臨床的治療方式

化學藥物的給藥•靜脈注射 : 大多數藥物長期低劑量灌注短期靜脈輸注靜脈推注

• 口服藥物 : VP-16, UFT, Xeloda, Hydroxyurea, 6-MP, 6-TG

化學藥物的給藥• 局部化學治療動脈內注射 : 肝臟腫瘤 腹腔內注射 : 卵巢癌 , 腸胃道癌肋膜腔 / 心包膜腔內注射 : 癌性積液 脊髓腔內注射 : 腦膜侵犯腦室內注射 : 腦膜侵犯 •經皮給藥 : 皮膚癌

化學藥物的靜脈給藥•依藥物 ,腫瘤的種類而有不同•不同的注射方式有不同的治療結果• 不同的注射方式有不同的毒性反應 Adriamycin, Epirubicin• 不同的注射方式有不同的殺死癌細胞的機制

5-FU

化學藥物給藥前應注意•確定病人姓名 , 診斷及化療醫囑•包括藥名清楚 , 劑量 , 給藥方式及時間

• Mitoxantrone, Mitomycin-C• Fluorouracil, Fluconazole• Vincristine, Vinblastine

化學藥物給藥前• 選定適當的注射位置• 不可使用軟組織少又有重要構造的部位 • 手背 , 腹股溝等部位• 不可使用血液流通不佳的部位• 不可使用關節部位

• 最佳位置為前臂手掌側• Port-A 為最佳輸注管道• 給藥前要確定靜脈管道通暢

化學藥物的給藥•給藥前再確定患者姓名 , 藥物名稱 , 劑量 ,給藥方式及灌注時間長短 .

•依醫囑所述方式給藥 , 包括給藥的順序 , 若有困難應立即聯絡醫師 .

Ara-C: push, subcutaneous, slow

infusion, long term infusion. etc. Cisplatin + Taxol. CDDP + MTX

化學藥物的給藥後• 不同的藥物的給藥後注意事項根據其常見毒性反應可能不同

• 注意嚴重的立即性毒性反應 Cisplatin: hydration & urine output Adriamycin/ Epirubicin: heart failure High dose Methotrexate: renal failure Cyclophosphamide: hemorrhagic cys

titis

Mucositis

Nausea/vomiting

Diarrhea

Cystitis

Sterility

Myalgia

Neuropathy

Alopecia

Pulmonary fibrosis

Cardiotoxicity

Local reaction

Renal failure

Myelosuppression

Phlebitis

Side effects of chemotherapy

INCREASED EFFICACYINCREASED EFFICACY

Different mechanisms of action Compatible side effects

Different mechanisms of resistance

ACTIVITYACTIVITY SAFETYSAFETY

Aim of combination therapy

會引起組織壞死的藥物• Vinka alkaloids: Vincristine(Oncovin), Vinb

lastine, Vinorelbine(Navelbine)• Anthracyclines: Epirubicin, Idarubicin• Mitomycin-C, BCNU, DTIC • Taxoids, Topotecan• Mithramycin, Nitrogen Mustard • VP-16, Cisplatin • Fludarabine, Gemcitabine, Irinotecan

化學藥物外滲的處置• 及早發現 ,立即停止輸注• 局部冷敷• Cold Compression for 30 min. Q6H

• 抬高患處 ,減少水腫• 治療可能之局部感染• 保持壞死皮膚所形成的水泡的完整及消毒• 開與止痛藥物 ,甚至 morphine

• 若有皮膚表面壞死 , 請教整形外科共同評估 ,甚至需要植皮 .

Chemotherapy-associated Emesis

Type of Treatment-related Emesis

• 1.Acute-phase symptoms:

Correlated with serotonin (5-HT) release

from enterochromaffin cells.

Emetic signals are propagated at local

5-HT3 receptors.

Type of Treatment-related Emesis

• 2.Delayed-phase symptoms:

Not to be related to serotonin.

Severity and duration often correlate with

drug dosage.

Nausea severity reportedly is similar during

both phases.

Type of Treatment-related Emesis

• 3.Anticipatory emetic symptoms:

An aversive conditioned response

Develops after repeated antineoplastic

treatments that are characterized by

poor emetic control.

Complete control throughout antineoplastic

treatment remains the best preventive strategy.

Antiemetic Options

1. Serotonin (5-HT3) receptor antagonists: Granisetron (Kytril)Ondansetron (Zofran)

• More effective and safer to use then other types of antiemetics.

Serotonin Antagonists

Ondansetron, Granisetron.

• 健保給付規定1. 骨髓移植患者接受高劑量化學治療時。2. 惡性腫瘤患者使用 cisplatin 劑量超過 50

mg/m2可預防性使用一日劑量。 Delay vomiting 每療程使用以不得超過五日為原則

Serotonin Antagonists

3. 惡性腫瘤患者使用中性致吐劑 cisplatin劑量 >30 ， < 50mg/m2可預防性使用一日劑量且發生嚴重延遲性嘔吐，使用 dexamethasone 及 metoclopramide 無效之病例，每療程使用以不得超過五日為原則。須檢附病歷摘要及使用 dexamethasone 及 metoclopramide 無效之記錄。

Serotonin Antagonists

4. 接受腹部放射照射之癌症病人，得依下列規範使用 ondansetron 及 granisetron ：

(1)total body or half body irradiation (2)pelvis or upper abdominal region of single irradi

ation dose> 6 Gy (3) 腹部放射治療中產生嘔吐，經使用 dexameth

asone 、 metoclopramide 或 prochlorperazine 等傳統止吐劑無效，仍發生嚴重嘔吐之患者。

Antiemetic Options

2. Steroids:Acute-phase symptoms: effective against mildly to moderately symptoms.

Delayed-phase symptoms:

most active agents.

Dexamethasone (2-20mg) & methylprednisolone

+ 5-HT3- and D2-receptor antagonists.

Antiemetic Options

3.  Metoclopramide: A weak competitive 5-HT3-receptor antagonist at high dosages.

4. Benzodiazepines: Lorazepam (Ativan).

5. Dopaminergic (D2)-receptor antagonists: Phenothiazines—Prochlorperazine. Butyrophenones—Haloperidol.

Neutropenic Fever

Neutropenic Fever

• Fever:

1 oral temperature > 38.3oC.

2 oral temperatures > 38oC, an hour apart.• Neutropenia:

ANC (Band + Neutrophil) < 500/mm3.

ANC 500/mm3 ~ 1,000/mm3, with a

predicted decline to < 500/mm3 within 48 hours.

Neutropenic Fever

In the absence of white cells:

1. Signs and symptoms of invasive

infections may be absent.

2. Infections can invade and spread quickly.

3. Fever may be the only manifestation of a

potentially life-threatening infection.

Neutropenic Fever

• Bacteremia: 10% to 20% • Gram-positive bacteremia: 70%

Coagulase-negative staphylococcus

S. aureus.• Gram-negative bacteremia: 30%

Escherichia coli, Klebsiella sp., Enterobacter sp.,

and rarely, Pseudomonas aeruginosa.

Neutropenic Fever

• Common sites of local infection:

The respiratory tract.

Sinuses.

Skin, soft tissue.

Venous catheter entry/exit sites.

Urinary tract.

Gastrointestinal tract: oral cavity, anus.

Neutropenic Fever

• Laboratory evaluation:

CBC/DC, Platelet.

Chemistries (hepatic and renal function).

Blood cultures.

U/A and U/C.

CXR.  

Any accessible sites of possible infection.

IDSA 2002 Guidelines CID 2002; 730-51

Vancomycin

• In initial empirical therapy: 1. Clinically suspected serious catheter- related infections. 2. Known colonization with penicillin- and cephalosporin-resistant pneumococci or MRSA. 3. B/C gram-(+) bacteria before final identification and susceptibility testing. 4. Hypotension or other evidence of CV impairment.

G-CSF

• Filgrastim, Lenograstim.• 健保給付規定 (1) 造血幹細胞骨髓移植 (2) 血液惡性疾病接受靜注化學治療後 (3) 先天性或循環性中性白血球低下症者 ( 當白血球數量少於 1000/mm3 ，或中性白血

球 (ANC) 少於 500/mm3) 。

G-CSF

(4) 其他惡性疾病患者在接受化學治療後，曾經發生白血球少於 1000/mm3，或中性白血球 (ANC) 少於 500/mm3者，在下一療程即可使用。

(5) 重度再生不良性貧血病人嚴重感染時使用，惟不得作為此類病人之預防性使用。

(6) 化學治療，併中性白血球小於 100 /mm3 癌症不受控制、肺炎、低血壓、多器官衰竭或侵犯性微菌感染等危機程度高之感染。

使用本品之患者應檢附治療記錄，其內容需包括診斷、白血球數量變化、所使用之化學治療藥物名稱、劑量及使用本品劑量，如白血球超過 4000/mm3時或中性白血球超過 2000/mm3時，應即停藥。

癌症疼痛Cancer Pain

晚期癌症患者常見症狀• Pain 89%• Fatigue 69%• Weakness 66%• Lack of energy 61%• Dry mouth 57%• Constipation 51%• Dyspnea 50%• Sleep Dis. 49%

• Depression 41%• Cough 38%• Nausea 36%• Edema 28%• Taste 28%• Hoarseness 24%• Anxiety 24%• Vomiting 23%

癌症疼痛可由一些簡單的治療方式在 90% 的患者得到有效的處置

Cancer pain can be managed effectively through relatively simple means in up to 90% of Patients.

Unfortunately, pain associated with cancer is frequently undertrea

ted.

疼痛評估的基本原則1. 相信病人的疼痛抱怨2. 仔細詢問癌症及疼痛相關病史3. 評估心理狀態、可請精神科協助4. 進行理學、神經學檢查5. 開立診斷方式：如 CT ， bone scan ， MRI6. 開始治療疼痛以便利適當檢驗7. 重新評估治療的反應8. 再設計、討論進一步治療方式

治療的基本原則• 1.Dose "by mouth" whenever possible.

• 2. Around the clock (ATC):

Basal analgesic administration

should not be based on an "as needed"

(prn) basis.

• 3.Dose by the WHO three-step ladder.

47

WHO Analgesic Ladder

Strong Opioids Non-OpioidsMorphine, Oxycodone,Hydromorphone,

TTS-Fentanyl, Methadon ,

Ste

p 3

Weak Opioids Non-OpioidsCodein, Dihydrocodein, Tramadol,

Tilidin/NaloxonSte

p 2

Non-OpioidsIbuprofen, Diclofenac, „Cox 2“

Paracetamol, Metamizol, Flupirtin

Ste

p 1

Co-analgesicsCo-analgesics

Strong Opioids

Morphine

Oxycodone

Hydromorphone

Fentanyl-TTS

Relation

1

2

7.5

100

Duration

8 - 12

8 - 12

8 - 12

48 - 72

Strong Opioids

• Morphine 10mg IV, IM

= 20mg SC

= 30mg PO

Morphine SR

Fentanyl-TTS

Dosage

If pain continues:

2 x 30 mg

A. 2 x 60 mg

B. 3 x 30 mg

never < 8 hrs

12 hrs

12 hrs

8 hrs

25 g/h

A. 50 g/h

B. 25 g/h

never < 2 days

Every 3. day

Every 3. day

Every 2. day

Dosage

If pain continues:

Rapid Calculation of Duragesic for Cancer Pain

Divide morphine equivalent dose (mg/day) PO by 2, round off to closest Duragesic patch in mcg/hr

EXAMPLE: Pt is on morphine (PO) 180 mg/day -> 180 /2 = 90, round off to Duragesic 100 mcg/hr

癌病代謝性急症 (Metabolic Emergencies in Oncology)

高血鈣症 :病程之變化• Early signs : fatique,lethargy, constipati

on, nausea and polyuria.

• Polyuria and nocturia secondary to renal tubular defect in water conservation. ==> Dehydration

• Stupor and coma are signs of severe hypercalcemia

高血鈣症的鑑別診斷• Endocrine/metabolic disorders• Cancer• Infectious disease• Renal insufficiency• Granulomatous diseases• Dietary/drug related• Milk_alkali syndrome• 高血鈣症最常見原因為癌症及副甲狀腺功能亢進

高血鈣症的治療• Saline hydration and diuretics

• Steroids: inhibit bone resorption and decrease GI tract calcium absorption.

most helpful in myeloma, leukemia and breast cancer

• Calcitonin: increase renal excretion and reduce bone resorption

高血鈣症的治療 (II)• Diphosphonates : reduce calcium flu

x from bone. osteoclast inhibitor.

• Gallium nitrate : inhibit bone resorption

• Mithramycin : kill osteoclasts.

腫瘤融解症候群

Tumor Lysis Syndrome

腫瘤細胞內含物及其代謝產物大量釋出於血液中所引發的全

身性反應Rapid release of intracellular

contents into the blood stream

主要代謝異常及其引致之病變

• Hyperuricemia: acute urate nephropahy --> obstruction and renal failure

• Hyperkalemia: cardiac arrhythmias

• Hyperphosphatemia : acute renal failure

• Hypocalcemia: muscle cramp, cardiac arrhythmias and tetany

Tumor Lysis 常見於下列腫瘤• Large tumor burdens, rapid proliferative fr

action and sensitive to chemotherapy.• High grade lymphoma ,such as Burkit's ly

mphoma.Leukemia with high leucocyte counts, CML in blastic crisis

• Rarely seen in solid tumors: small cell lung ca, breast cancer

• Few hours to few days after initiation of treatment

Tumor Lysis 臨床症狀• Oliguria-azotemia

• Hyperkalemia, hyperphosphatemia, hyperuricemia

• Tetany

• Cardiac arrhythmia

• Hypotension-shock

• Cardiac arrest

如何早期發現 Tumor Lysis

• 密切檢測• Chemistry screen : K+, Ca++, uric acid, PO

4,LDH,BUN,creatinine

Tumor Lysis 的治療方式• Prevention for high risk patients• Hydration 2500-3000ml/sqm/day• Sodium bicarbonate for alkalinizatio

n to urine PH >7 (50-100meq / L)• Allopurinol 10 mg/kg/day ,, 300mg/d

ay (12 hrs before C/T), reduces to 100mg/day if creatinine > 2mg%

Tumor Lysis 的治療方式• Monitor elctrolytes, uric acid, phosphorus,

calcium and creatinine daily for 1 week• once tumor lysis developed, monitor the ly

tes every few hours.• Hypocalcemia : calcium gluconate• Hyperkalemia : Kayexalate (15 gm q6h), 2

0% dextrose with 10-20 U of insulin /liter.• Hyperphosphatemia : aluminum gel 30cc q

3-4 hrs

Tumor Lysis 的治療方式

•早期使用血液透析• potassium >6 mEq/l

• uric acid > 10mg/dl

• phospharus > 10 mg/dl,

• symptomatic hypocalcemia and fluid overload.

脊索壓迫症候群Spinal Cord Compression

脊索 Spinal cord壓迫症候群•硬腦膜外 extradural 的脊索壓迫症候是惡性腫瘤常見的神經學併發症 .

•不論是硬腦膜外的腫瘤或是較罕見的由脊髓內腫瘤所引起者 ,如未有立即的診斷及迅速的治療 , 皆可引起永久性的神經系統傷害 .

部位分布• 硬腦膜外轉移

頸椎 10%

胸椎 70%

腰椎及薦椎 20%

可能的腫瘤• 任何可轉移的腫瘤皆可發生• 肺癌約佔了 15%

• 乳癌 , 攝護腺癌 , 淋巴瘤 , 骨髓瘤及原發布為不明的轉移癌則各約佔 了 10%.

臨床徵候•被壓迫脊髓相對神經分布部位的疼痛 ,•腸道及膀胱自主神經控制的異常 (autonomic dysfunction),

•肢體無力及被壓迫脊髓相對神經節以下部位的感覺喪失 . 疼痛可以是局部的也可以是神經根壓迫式 (radicular pain).

•受侵犯部位的脊椎可有壓痛 (point tenderness).

放射線及實驗室的診斷•要做可能侵犯部位的脊椎 X光檢查 , 也常可見有脊椎骨的破壞 .

•傳統上是用脊髓腔攝影 (myelography)來確定病灶的範圍 ,阻斷的部位及嚴重程度及是否有其他部位尚未有症狀的脊髓壓迫 .

• 核磁共振攝影成為這類病患最佳的檢查方式

臨床症狀• 90% 以上的患者會有脊椎中線或脊柱旁區域 的

疼痛 . 通常再躺下時會加劇 , 而在站著或坐著時會減輕

• 神經根的壓迫性疼痛 (Radicular pain) 是一常見的早期症狀 , 疼痛與脊椎間盤疾病 , 肋膜發炎 , 膽囊炎及胰臟炎的疼痛類似 .

• 下肢的無力及麻木感但無感覺異常 (paresthesias)

• 便秘或是大解失禁

理學檢查• 脊椎部位的壓痛 . 若加上脊髓病變的徵候則極

有可能有硬腦膜上的轉移腫瘤 . • 被壓迫的脊椎部位以下可出現 DTR 增加 (hyperactive)

Babinski 徵候陽性 運動無力 感覺異常 (hypesthesia)

肛門括約肌張力減低

脊椎 X 光檢查• 癌症患者有背痛者皆應做脊椎 X 光檢查• 脊椎 X 光檢查在 80% 的患者可判斷有無

硬腦膜外的轉移 .

• 最常見的有 pedicles 的喪失 , 脊椎體的破壞及脊椎體的崩解 (collapse)

臨床處置及治療•懷疑有這類併發症的患者需立即住院並會診神經外科醫師及放射腫瘤專科醫師 .

•需要立即且積極的使用類固醇 ( 例如 dexamethasone, 4-10 mg IV q6h)

•緊急的放射治療或是神經外科手術減壓來治療 .

Highlight of Leukemia ManagementHighlight of Leukemia Management

Bleeding diasthesisBleeding diasthesis

Risks of life-threatening hemorrhageRisks of life-threatening hemorrhage

-- ICH, DIC, pulmonary hemorrhage-- ICH, DIC, pulmonary hemorrhage

Fever, neutropenic feverFever, neutropenic fever

HyperleucocytosisHyperleucocytosis

Severe anemiaSevere anemia

OrganomegalyOrganomegaly

Cytochemical stainingCytochemical staining

Myeloperoxidase (MPO): AML M1,2,3,4,5Myeloperoxidase (MPO): AML M1,2,3,4,5

Chloroacetate esterase (CAE): M1,2,3,4Chloroacetate esterase (CAE): M1,2,3,4

Alpha-naphthyl butyrate (ANBE): M4,M5Alpha-naphthyl butyrate (ANBE): M4,M5

PAS: ALL, AML (15%)PAS: ALL, AML (15%)

Tdt: ALLTdt: ALL

LAP score: leukocyte ALK P stain (80-100)LAP score: leukocyte ALK P stain (80-100)

LAP < 20 in CML, PNHLAP < 20 in CML, PNH

Approach of Acute LeukemiaApproach of Acute LeukemiaBlasts 30%≧

Peroxidase stain

Positive Negative

CAE PAS

Positive Negative POS Neg

AML

M1-M4

CD13,14,33,65

ANBE ALL

AML M6,7

CD41,61

Glycophyrin

AML Mo

CD13,33,65

ALL

CD2,7,10,19

M4,M5

CHROMOSOME ANALYSISCHROMOSOME ANALYSIS

For diagnosisFor diagnosist(9,22)t(9,22) : CML: CMLt(2,5)t(2,5) : Ki-1 lymphoma ALCL: Ki-1 lymphoma ALCLt(4,11)t(4,11) : biphenotypic leukemia: biphenotypic leukemia

For prognosisFor prognosisFavorableFavorable : t(8,21), t(15,17), inv(16): t(8,21), t(15,17), inv(16)UnfavorableUnfavorable : -5/del, -7/del, +8: -5/del, -7/del, +8

For detection of minimal residual diseaseFor detection of minimal residual disease

AML-TreatmentAML-Treatment

Remission inductionRemission induction: Ara-c 100mg/m: Ara-c 100mg/m22/d X7, Idarubi/d X7, Idarubicin 12mg / mcin 12mg / m22/d X3/d X3ConsolidationConsolidation: Standard Ara-c 100mg/m: Standard Ara-c 100mg/m2 X2 X 5, Ida X2 5, Ida X2

High dose Ara-c 1-3gm/mHigh dose Ara-c 1-3gm/m22 Bid X 4da Bid X 4daysysMaintenanceMaintenance: not helpful: not helpfulStem cell transplantStem cell transplant—— Allo-BMT, Allo-PBSCTAllo-BMT, Allo-PBSCT— — ABMT, autologous PBSCTABMT, autologous PBSCT— — MUD, no better than HiDACMUD, no better than HiDAC— — Allo-minitransplant (mixed chimerism)Allo-minitransplant (mixed chimerism)Acute GVHD, VOD, interstitial pneumonia, Acute GVHD, VOD, interstitial pneumonia, TRM 30%TRM 30%

COMMON CHEMOTHERAPY REGIMENCOMMON CHEMOTHERAPY REGIMEN

AMLAMLA) 7 + 3A) 7 + 3

• Ara - C 100mg/mAra - C 100mg/m22 + N/S or D5W + N/S or D5W500ml 500ml CIV CIV qd or bidqd or bid

• Idarubicin 10-12mg/mIdarubicin 10-12mg/m22××d + N/S 100mld + N/S 100mlIV infusion for 1hrIV infusion for 1hr

(Mitoxantrone same as Idarubicin)(Mitoxantrone same as Idarubicin)B) HDACB) HDAC

• Ara-C 1gm-3gm/mAra-C 1gm-3gm/m22××bibid + N/S 500mld + N/S 500mlIV infusion for IV infusion for 3-4 hours3-4 hours

Acute Promyelocytic Leukemia ( M3 ) Acute Promyelocytic Leukemia ( M3 )

Remission inductionRemission induction : ATRA 45/m2/d : ATRA 45/m2/d WBC > 3000/cumm : ATRA + Idarubicin 12 mg/m2WBC > 3000/cumm : ATRA + Idarubicin 12 mg/m2 WBC > 10000/cumm : ATRA + Ida × 3 + Ara – CWBC > 10000/cumm : ATRA + Ida × 3 + Ara – C

Consolidation Consolidation : 7+3 then HIDAC + DNR or IDA: 7+3 then HIDAC + DNR or IDA

MaintenanceMaintenance : 1 yr ATRA or observation ( APL 93 trial ) : 1 yr ATRA or observation ( APL 93 trial ) 5 yr DFS = 70 %5 yr DFS = 70 %

Retinoid acid syndromeRetinoid acid syndrome : : weight gain ,hyperleucocytosis ,interstitial pulmonary iweight gain ,hyperleucocytosis ,interstitial pulmonary i

nfiltrate , pleural or pericardial effusion , hypoxemia , hnfiltrate , pleural or pericardial effusion , hypoxemia , hypotensionypotension

TreatmentTreatment : dexamethasone 10 mg bid × 3 day : dexamethasone 10 mg bid × 3 day

Treatment of ALLTreatment of ALL

Remission inductionRemission induction : : - standard risk : vincristin , prednisolone- standard risk : vincristin , prednisolone - high risk : vincristin , PDN , doxorubicin- high risk : vincristin , PDN , doxorubicin

Early intensificationEarly intensification : L – asparaginase, MTX : L – asparaginase, MTX

CNS prophylaxisCNS prophylaxis : MTX , dexamethasone : MTX , dexamethasoneConsolidationConsolidation : Ara – C , cyclophosphamide : Ara – C , cyclophosphamide

Maintenance Maintenance : 6 MP/MTX , VCR/PDN , VP-16: 6 MP/MTX , VCR/PDN , VP-16ALLO-BMT, PBSCTALLO-BMT, PBSCT ( auto, MUD )( auto, MUD )

Clinical Practice in WardClinical Practice in Ward

1st WK: FAB subtype (confirm DX), Karyotype, s1st WK: FAB subtype (confirm DX), Karyotype, set IV line, cyto-reduction , initiate C/T, blood comet IV line, cyto-reduction , initiate C/T, blood component, control infection, risk factorsponent, control infection, risk factors2nd WK: C/T, infection, hemorrhage2nd WK: C/T, infection, hemorrhage3rd WK: d15 BM exam, folic acid, G-CSF3rd WK: d15 BM exam, folic acid, G-CSF

fungal infection, HSV, diarrheafungal infection, HSV, diarrhea4th WK: recovery of CBC, fever should subside 4th WK: recovery of CBC, fever should subside otherwise consider partial remission or fungal infotherwise consider partial remission or fungal infectionectionAlways check skin, oral cavity, bowel, anus, veniAlways check skin, oral cavity, bowel, anus, venipuncture site, UA, CXRpuncture site, UA, CXR

MANAGEMENT OF ACUTE LEUKEMIASMANAGEMENT OF ACUTE LEUKEMIASSET IV line, CVP, PICC or port-ASET IV line, CVP, PICC or port-ABlood component transfusionBlood component transfusionsupportive care for bleeding and infectionsupportive care for bleeding and infection– blood culture in febrile patientsblood culture in febrile patients– empirical antibioticsempirical antibioticsReverse isolation, single room or HEPAReverse isolation, single room or HEPAGut decontaminationGut decontaminationBone marrow aspiration & biopsyBone marrow aspiration & biopsyFlow cytometry for leukemia markersFlow cytometry for leukemia markers– lymphoid and myeloidlymphoid and myeloidChromosome, cytogenetic studyChromosome, cytogenetic studyCytochemical stainCytochemical stainPCR, ISHPCR, ISH

NOTICE OF PLATELET TRANSFUSION NOTICE OF PLATELET TRANSFUSION

Hazards of low platelet countHazards of low platelet count– plateletplatelet 　 　 70 - 80K70 - 80K guarantee safety for operaguarantee safety for opera

tiontion– plateletplatelet 　 ＜ 　 ＜ 50K50K bleeding in minor traumableeding in minor trauma– plateletplatelet 　 　 ＜＜ 20K20K spontaneous bleedingspontaneous bleeding

Bleeding diathesisBleeding diathesis– DIC, sepsis, aplastic anemiaDIC, sepsis, aplastic anemia– acute leukemiasacute leukemias– high dose chemotherapyhigh dose chemotherapy– stem cell transplantationstem cell transplantation– thrombocytopenia of any causethrombocytopenia of any cause

Fever in Acute LeukemiaFever in Acute Leukemia

Before admission: pneumonia, leukemiaBefore admission: pneumonia, leukemia1st 7 days: infection, G(-) bacilli, Ara-c1st 7 days: infection, G(-) bacilli, Ara-c22ndnd 7 days: infection, G(+) cocci, blood transfusi 7 days: infection, G(+) cocci, blood transfusionon33rdrd 7 days: G-CSF, blood transfusion, G(+)/G(-) 7 days: G-CSF, blood transfusion, G(+)/G(-)

fungi, herpes simplex HSVfungi, herpes simplex HSVNEC: necrotizing neutropenic enterocolitisNEC: necrotizing neutropenic enterocolitisCommon site of infection: mucositis, dental, perCommon site of infection: mucositis, dental, perianal infection, IV catheter, skin, ENT, lung, G-I.ianal infection, IV catheter, skin, ENT, lung, G-I.

Thanks for attentionThanks for attention